VA Health Care: Improved Screening of Practitioners Would Reduce 
Risk to Veterans (31-MAR-04, GAO-04-566).			 
                                                                 
Cases of practitioners causing intentional harm to patients have 
raised concerns about the Department of Veterans Affairs' (VA)	 
screening of practitioners' professional credentials and personal
backgrounds. GAO was asked to (1) identify key VA screening	 
requirements, (2) evaluate their adequacy, and (3) assess	 
compliance with these screening requirements. GAO reviewed VA's  
policies and identified key VA screening requirements for 43	 
health care occupations; interviewed officials from VA, licensing
boards, and certifying organizations; and randomly sampled about 
100 practitioners' personnel files at each of four VA facilities 
we visited.							 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-04-566 					        
    ACCNO:   A09621						        
  TITLE:     VA Health Care: Improved Screening of Practitioners Would
Reduce Risk to Veterans 					 
     DATE:   03/31/2004 
  SUBJECT:   Crimes or offenses 				 
	     Data bases 					 
	     Health care personnel				 
	     Hiring policies					 
	     Licenses						 
	     Physicians 					 
	     Evaluation methods 				 
	     Personnel evaluation				 

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GAO-04-566

United States General Accounting Office

GAO 	Report to the Chairman, Subcommittee on Oversight and Investigations,
            Committee on Veterans' Affairs, House of Representatives

March 2004

VA HEALTH CARE

       Improved Screening of Practitioners Would Reduce Risk to Veterans

GAO-04-566

Highlights of GAO-04-566, a report to the Chairman, Subcommittee on
Oversight and Investigations, Committee on Veterans' Affairs, House of
Representatives

Cases of practitioners causing intentional harm to patients have raised
concerns about VA's screening of practitioners' professional credentials
and personal backgrounds. GAO was asked to (1) identify key VA screening
requirements, (2) evaluate their adequacy, and (3) assess compliance with
these screening requirements. GAO reviewed VA's policies and identified
key VA screening requirements for 43 health care occupations; interviewed
officials from VA, licensing boards, and certifying organizations; and
randomly sampled about 100 practitioners' personnel files at each of four
VA facilities we visited.

GAO recommends that VA expand its existing verification process to require
that all state licenses and national certificates held by all
practitioners be verified by contacting the appropriate licensing boards
and national certifying organizations, expand the query of a national
database to include all licensed practitioners, and fingerprint all
practitioners who have direct patient care

March 2004

VA HEALTH CARE

Improved Screening of Practitioners Would Reduce Risk to Veterans

GAO identified key screening requirements that VA uses to verify the
professional credentials and personal backgrounds of its health care
practitioners. These requirements include verifying professional
credentials; completing background investigations for certain
practitioners, including fingerprinting to check for criminal histories;
and checking national databases that contain reports of practitioners who
have been professionally disciplined or excluded from federal health care
programs.

GAO found adequate screening requirements for certain practitioners, such
as physicians, for whom all licenses are verified by contacting state
licensing boards. However, screening requirements for others, such as
currently employed nurses and respiratory therapists, are less stringent
because they do not require verification of all licenses and national
certificates. Moreover, they require only physical inspection of the
credential rather than contacting state licensing boards and national
certifying organizations. Physical inspection alone can be misleading; not
all credentials indicate whether they are restricted, and credentials can
be forged. VA also does not require facility officials to query, for other
than physicians and dentists, a national database that includes reports of
disciplinary actions involving all licensed practitioners. In addition,
many practitioners with direct patient care access, such as medical
residents, are not required to undergo background investigations,
including fingerprinting to check for criminal histories.

Four Facilities' Compliance with Existing Key VA Screening Requirements

Compliance with key screening requirements

Key screening requirements Facility A Facility B Facility C Facility D

Credentials of applicants verified A  WA  A
Credentials of employed practitioners W  WW  W
verified
List of Excluded Individuals and Entities W  AA  A
queried for applicants
Background investigation completed or W  AA  W
requested for employed practitioners

access. GAO also recommends that VA conduct oversight of its facilities to
ensure their compliance with all key screening requirements. VA generally
agreed with GAO's findings and will develop a detailed action plan to
implement the recommendations.

www.gao.gov/cgi-bin/getrpt?GAO-04-566.

To view the full product, including the scope and methodology, click on
the link above. For more information, contact Cynthia A. Bascetta at (202)
512-7101.

Declaration for Federal Employment form W  WW  Wcompleted for employed
practitioners

Source: GAO analysis of VA facility files.

W Indicates a compliance rate of 90 percent or greater.

A Indicates a compliance rate of less than 90 percent.

VA has not conducted oversight of its facilities' compliance with the key
screening requirements. This pattern of mixed compliance and the gaps in
key VA screening requirements creates vulnerabilities to the extent that
VA remains unaware of practitioners who could place patients at risk.

Contents

  Letter

Results in Brief
Background
VA Policy Requires Its Facilities to Check Many Practitioners'

Professional Credentials and Personal Backgrounds Gaps in Key VA Screening
Requirements Create Vulnerabilities VA Facilities Did Not Comply with All
of the Key VA Screening

Requirements Conclusions Recommendations for Executive Action Agency
Comments 1

3 5

6 12

17 20 21 22

Appendix I Scope and Methodology

Appendix II Results of Our Compliance Reviews at VA Facilities

        Appendix III Comments from the Department of Veterans Affairs 31

  Appendix IV GAO Contact and Staff Acknowledgments 33

GAO Contact 33 Acknowledgments 33

  Tables

Table 1: Types of Practitioners VA Exempts from Background Investigations
16 Table 2: Facilities' Rate of Compliance with Existing Key VA Screening
Requirements 18 Table 3: State Licensure and National Certification
Requirements for the 43 VA Occupations 25 Table 4: VA Facility Compliance
with Key Screening RequirementsProfessional Credentials
Verification 29 Table 5: Facility Compliance with Key Screening
RequirementsPersonal Background Screening 29

Table 6: Average Number of Days from Obtaining Background Investigation
Results to VA Facility Action (August 1, 2002, to August 23, 2003)

  Figures

Figure 1: VA's Process for Credentials Verification with State Licensing
Boards and National Certifying Organizations 8 Figure 2: Gaps in Group B
Employed Practitioners' Credentials Verification with State Licensing
Boards 13

Figure 3: Gaps in Group C Applicants' and Employed Practitioners'
Credentials Verification with State Licensing Boards and National
Certifying Organizations 15

Abbreviations

FSMB Federation of State Medical Boards
HIPDB Healthcare Integrity and Protection Data Bank
LEIE List of Excluded Individuals and Entities
NPDB National Practitioner Data Bank
OPM Office of Personnel Management
SLB state licensing board
VA Department of Veterans Affairs

This is a work of the U.S. government and is not subject to copyright
protection in the United States. It may be reproduced and distributed in
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separately.

United States General Accounting Office Washington, DC 20548

March 31, 2004

The Honorable Steven Buyer
Chairman
Subcommittee on Oversight and Investigations
Committee on Veterans' Affairs
House of Representatives

Dear Mr. Chairman:

The Department of Veterans Affairs (VA) is responsible for safeguarding
veterans receiving health care in its facilities by ensuring that its
health
care practitioners are qualified to provide care to their patients. VA
employs about 190,000 individuals including physicians, nurses,
pharmacists, and therapists at its facilities, and it supplements these
practitioners with contract staff, medical consultants, and medical
residents.1 VA has screening requirements intended to help ensure that its
health care practitioners' professional credentials are verified and their
personal backgrounds checked for evidence of incompetence or criminal
behavior. According to medical forensic experts, the deliberate harm of
patients by health care practitioners is a problem in the health care
sector,
and VA's requirements are intended to minimize the chance of veterans
receiving care from someone who is incompetent or may intentionally
harm them.

Events at VA facilities have raised concerns about VA's screening of the
professional credentials and personal backgrounds of health care
practitioners at its facilities. In 1993, Dr. Michael Joseph Swango
entered
the VA health care system as a medical resident, although before entering
the residency program he had been convicted and imprisoned for 2 years
for aggravated battery against his fellow employees. Dr. Swango had
admitted to medical school officials that he had a prior arrest and
conviction, but lied about the nature of the crime. In 2000, he pleaded
guilty to murdering three veterans at the VA facility located in
Northport,
New York, and received a sentence of three consecutive life terms without
the possibility of parole. In another case, in 2000, events at the VA
facility

1Contract staff may include intensive care nurses, emergency room
physicians, or respiratory therapists. These staff have access to and
provide care to patients.

in Albany, New York, raised concerns about VA's process for checking the
credentials of individuals employed at its facilities. VA hired a research
assistant to help administer several cancer studies. The research
assistant had lost his medical license because he had forged his medical
credentials. Once at VA, the research assistant allegedly falsified data
that were used to qualify veterans for cancer studies, and this may have
resulted in the untimely deaths of several veterans. In 2003, the
researcher was indicted in federal court on charges including
manslaughter, criminally negligent homicide, and fraud.

You asked that we examine VA's policies and practices intended to ensure
that health care practitioners at its facilities have appropriate
professional credentials and personal backgrounds to provide care to
veterans. Specifically, we (1) identified key VA screening requirements
for its health care practitioners, (2) determined the adequacy of these
screening requirements, and (3) assessed the extent to which selected VA
facilities complied with these screening requirements.

We reviewed health care occupations in VA and selected 43 occupations in
which practitioners have direct patient care access or have an impact on
patient care. See appendix I for a list of the 43 health care occupations
included in our study. We reviewed VA employment screening policies and
practices to identify those requirements that applied to the selected
occupations and were key requirements for safeguarding veterans receiving
health care in VA facilities.2 To determine the adequacy of the key
screening requirements, we examined whether they were complete, and
whether VA applied them to all applicants, current employees, contract
staff, medical residents, and volunteers. We also interviewed VA human
resource officials, VA headquarters and VA facility officials, and
facility practitioners; representatives of state licensing boards and
national certifying organizations; and officials and representatives of
organizations that operate national databases containing information on
state licenses and national certificates. We also reviewed VA's policy on
background investigations to determine its criteria for conducting
background investigations. To assess the extent to which VA facilities
complied with the key screening requirements, we visited four VA
facilities and reviewed personnel files for practitioners at each site.
From VA's automated pay

2Although VA has many employment screening requirements, such as whether
the applicant is a United States citizen, we selected only those
requirements that pertain to patient safety, such as verification of
credentials and background investigations.

  Results in Brief

system, we selected a statistically random sample of 100 current
practitioners in the 43 occupations for each facility we visited. We
reviewed these practitioners' files to determine whether the facilities
had documentation that demonstrated compliance with key VA screening
requirements. We visited facilities located in Big Spring, Texas; New
Orleans, Louisiana; Seattle, Washington; and the District of Columbia,
based on geographic variation, affiliations with medical schools to train
residents, and types of health care services provided. Of the four
facilities we visited, three are large facilities located in major
metropolitan areas and are affiliated with at least one medical school.
The remaining facility is small, providing mainly primary care and
long-term care services to veterans and is located in a rural area.
Additionally, from the four facilities we visited and from six other
facilities we selected based on geographic variation, we obtained
documentation on how quickly facilities took action after obtaining the
results of background investigations. Our results cannot be generalized to
other facilities. For a complete description of our scope and methodology,
see appendix I. Our work was conducted from August 2003 through March 2004
in accordance with generally accepted government auditing standards.

We identified key screening requirements in VA's policies for checking the
professional credentials and personal backgrounds of health care
practitioners in its facilities. These requirements are in place to verify
state licenses and national certificates for applicants VA intends to hire
and for continued employment of practitioners; to check health care
practitioners against national databases that contain reports of
professional disciplinary actions and criminal convictions; and to
investigate the personal backgrounds of health care practitioners,
including checking fingerprints against a fingerprint-based criminal
history database.

We found adequate screening requirements for certain practitioners, such
as physicians and dentists. These screening requirements include having
facility officials verify all physicians' and dentists' licenses by
contacting state licensing boards for applicants VA intends to hire and
periodically for their continued employment. Screening requirements for
other practitioners, such as currently employed nurses, are less stringent
because they do not require that VA facility officials check all licenses.
Moreover, they do not require contacting state licensing boards, but
instead require physical inspection of the license only. VA does not
require verifying national certificatesthe credentials held by
other health care practitioners, such as respiratory therapistsby
contacting the national certifying organizations for applicants VA intends
to hire and periodically

for their continued employment. Physical inspection of credentials alone
can be misleading; not all state licenses and national certificates
indicate whether they are restricted, and licenses and certificates can be
forged. Also, other than for physicians and dentists, VA does not require
facility officials to query a national database that contains reports of
disciplinary actions and criminal convictions involving all licensed
practitioners. In addition, many practitioners with direct patient care
access, such as medical residents, are not required to undergo background
investigations, including fingerprinting to check for criminal records.
These gaps create vulnerabilities because VA may remain unaware of health
care practitioners who could place patients at risk.

In the four facilities we visited, we found mixed compliance with the
existing key VA screening requirements. All facilities generally checked
the professional credentials of practitioners periodically for continued
employment. However, they were less compliant in checking the professional
credentials of applicants that they intended to hire. Furthermore, VA
facilities varied in how quickly they took action after obtaining the
results of background investigations. During the site visit at one
facility, we discovered returned background investigation results that
were over a year old but had not been reviewed. We brought them to the
attention of facility officials, who reviewed the reports and then
terminated a nursing assistant who had been fired by a previous employer
for patient abuse. Although VA established an office more than a year ago
to perform oversight of human resources functions, including whether its
facilities comply with these key screening requirements, it has not
started these reviews. There is no VA policy outlining the human resources
program evaluations to be performed by this office, and the resources have
not been provided to support the functions of this office.

To better ensure the safety of veterans receiving health care at VA
facilities, we recommend that VA conduct more thorough screening of both
applicants it intends to hire and current employees by expanding the
verification requirement that facility officials contact state licensing
boards and national certifying organizations to include all state licenses
and national certificates held by practitioners; expanding the query of a
national database to include all licensed practitioners that VA intends to
hire and periodically for continued employment; and requiring fingerprint
checks for all health care practitioners who were previously exempted from
background investigations and who have direct patient care access.
Furthermore, VA should conduct oversight to help ensure that facilities
comply with all key screening requirements for applicants and current
employees. In commenting on a draft of this report, VA generally agreed

Background

with our findings and conclusions and stated that it would provide details
on how it plans to address our recommendations when the final report is
issued.

VA operates the largest integrated health care system in the United
States, providing care to nearly 5 million veterans per year. The VA
health care system consists of hospitals, ambulatory clinics, nursing
homes, residential rehabilitation treatment programs, and readjustment
counseling centers. In addition to providing medical care, VA is the
largest educator of health care professionals, training more than 28,000
medical residents annually, as well as other types of trainees.

State licenses are issued by state licensing boards, which generally
establish state licensing requirements governing their licensed
practitioners.3 Current and unrestricted licenses are licenses that are in
good standing in the states that issued them, and licensed practitioners
may hold licenses from more than one state. To keep a license current,
practitioners must renew their licenses before they expire and meet
renewal requirements established by state licensing boards, such as
continuing education. Renewal procedures and requirements vary by state
and occupation. When licensing boards discover violations of licensing
practices, such as the abuse of prescription drugs or the provision of
poor quality of care that results in adverse health effects, they may
place restrictions on licenses or revoke them. Restrictions from a state
licensing board can limit or prohibit a practitioner from practicing in
that particular state. Some, but not all, issued state licenses are marked
in such a way as to indicate that the licenses have had restrictions
placed on them. Generally, state licensing boards maintain a database of
information on restrictions, which employers can often obtain at no cost
either by accessing the information on a board's Web site or by contacting
the board directly.

National certificates are issued by national certifying organizations,
which are separate and independent from state licensing boards.4 These
organizations establish professional standards that are national in scope
for certain occupations, such as respiratory and occupational therapists.

3State licenses are issued by offices in states, territories,
commonwealths, or the District of Columbia, collectively referred to as
state licensing boards.

4Some practitioners may hold both a national certificate and a state
license.

  VA Policy Requires Its Facilities to Check Many Practitioners' Professional
  Credentials and Personal Backgrounds

Practitioners who are required to have a national certificate to practice
in VA may renew these credentials periodically by paying a fee and
verifying that they obtained required educational credit hours. National
certifying organizations can place restrictions on a certification or
revoke certification for violations of the organization's professional
standards. Like state licensing boards, national certifying organizations
maintain a database of information on disciplinary actions taken against
practitioners with national certificates and many can be accessed at no
cost.

We identified key VA screening requirements that are intended to ensure
that VA facilities employ health care practitioners who have valid
professional credentials and personal backgrounds appropriate to deliver
safe health care to veterans. Officials at VA facilities are required to
verify whether credentialsstate licenses and national
certificatesheld by applicants and employees are current and
unrestricted.5 VA also requires its facilities to check the names of all
applicants VA intends to hire against a federal list of individuals who
have been excluded from participation in any federal health care programs
and to compare applicants' educational institutions against lists of
fraudulent institutions.6 Additionally, VA requires that individuals in
certain positions undergo a background investigation, which includes
checking their fingerprints against a fingerprint-based criminal history
database.

5Professional credentials held by practitioners may include licenses,
registrations, and certifications. We refer to these credentials as state
licenses or national certificates.

6The term applicants refers to those practitioners that VA facility
officials plan to hire.

    VA Policy Requires Verification of the Status of State Licenses and National
    Certificates

VA policy requires officials at its facilities to screen applicants to
determine whether they possess at least one current and unrestricted state
license or an appropriate national certificate, whichever is applicable
for the position they seek. We classified VA's practitioners into three
groups, depending upon the credentials and the verification process VA
requires for employment. Figure 1 illustrates VA's process for credentials
verification with state licensing boards and national certifying
organizations for these groups for applicants VA intends to hire and for
employed practitioners, whose credentials are checked periodically.7 8
Groups A and B represent practitioners who must be licensed to work in VA.
However, the requirements and process VA uses to verify professional
credentials is different for each of these groups. Group C represents
practitioners who must have a national certificate to work in VA and may
also have a state license.

7The frequency of when practitioners' credentials are checked depends on
their occupation and the requirements of the state or national
organization that issued the credential.

8We use the term employed practitioners to refer to practitioners who have
been hired by VA and to distinguish them from practitioners who have
applied for VA employment, but have not been hired.

Figure 1: VA's Process for Credentials Verification with State Licensing
Boards and National Certifying Organizations

Note: Groups A and B represent practitioners who must be licensed to work
in VA. Some group B psychologists and social workers may undergo the same
credentials verification process as practitioners in group A. Group C
represents practitioners who must have a national certificate to work in
VA and may also have a state license.

aPhysician assistants are not required to have a license to work in VA,
but their credentials are verified using a process that is similar to
other group A practitioners.

The process used to screen applicants in all three groups has two stages.
First, applicants are required to disclose, if applicable, their state
licenses and national certificates. Second, VA facility officials are
required to verify whether applicants' state licenses or national
certificates are current and unrestricted. To verify applicants'
credentials, VA officials are required to

either contact state licensing boards or to physically inspect an
applicant's national certificate. Officials are also required to document
that they verified the status of the professional credentials.

VA also has requirements for verifying the credentials of its employed
practitioners. Like the verification process for applicants, this process
involves employed practitioners' disclosures and VA verification of that
information. VA employed practitioners in group A are required to disclose
all of their current licenses, while those in group B must disclose only
one license. For employed practitioners in group A, facility officials are
also required to determine if any expired licenses disclosed as current
and unrestricted at the beginning of employment had restrictions placed on
them prior to their expiration. VA depends on its employed practitioners
in group B to inform facility officials of any change in the status of
their license, including any that have expired. Employed practitioners in
group C must disclose a national certificate. VA officials must confirm
that the disclosed licenses and certificates are current and unrestricted.
For group A practitioners, VA facility officials contact the appropriate
state licensing boards directly; for groups B and C they physically
inspect the state license or national certificate. VA officials verify
these credentials periodically depending on the occupation and the
requirements of the state or national organization that issued the license
or certificate. For example, a registered nurse with a state license from
Virginia must renew the license every 3 years, while a respiratory
therapist must renew the national certificate every 5 years.9 VA officials
are required to document these verifications.

If VA's verification process identifies that a state licensing board or
national certifying organization took disciplinary action against a
practitioner, facility officials are required to determine the
circumstances of the disciplinary action. Licensing boards and certifying
organizations have various options for disciplining practitioners. For
example, a nurse who is abusing drugs and voluntarily enters a drug abuse
program may retain a license to practice with supervision when
administering drugs. In contrast, a physician whose treatment results in
the death or the permanent disability of a patient may have a license
revoked. On the basis of a review of the action taken by the state
licensing board or national

9The requirement for respiratory therapists to renew their national
certificate every 5 years became effective in July 2002 and affects those
national certificates obtained after June 30, 2002.

certifying organization, VA officials are to determine whether an
applicant should be hired or an employed practitioner should be retained
or terminated.

To supplement its checks with state licensing boards, VA has requirements
for searching for disciplinary actions taken against licensed
practitioners that might not have been disclosed by physician and dentist
applicants and employed practitioners. VA requires its facilities to check
national databases for information on disciplinary actions taken against
these practitioners. Specifically, VA requires that facility officials
query the Federation of State Medical Boards (FSMB) database, which
includes records of disciplinary actions taken against physicians by all
state licensing boards.10 Similarly, VA requires facility officials to
query the National Practitioner Data Bank (NPDB), which contains
information including disciplinary actions taken against physicians and
dentists.11 Facility officials must document the results of these queries.

    VA Policy Requires Checks of Applicants and Their Credentials against Lists
    Designed to Prevent Fraud and Abuse

VA policy requires its facilities to check the names of all applicants VA
intends to hire against a federal list of individuals who have been
excluded from participation in any federal health care program.12 The
list, referred to as the List of Excluded Individuals and Entities (LEIE),
is maintained by the Department of Health and Human Services' Office of
Inspector General. Since March 1999, VA facilities are to electronically
query the LEIE Web site on all applicants prior to employment.

VA also requires its facilities to make sure that an applicant's
educational degrees are authentic. VA requires that applicants for some
positions, such as social workers, have degrees from accredited
institutions. To prevent

10FSMB represents state medical licensing boards and establishes standards
for physician licensure and practice. FSMB operates a national database to
collect, record, and distribute to state medical boards and other
appropriate agencies data on disciplinary actions taken against physicians
by the boards and other governmental authorities.

11The Health Resources and Services Administration of the Department of
Health and Human Services is responsible for the management of NPDB.

12The Balanced Budget Act significantly expanded the authority of the
Department of Health and Human Services to exclude certain individuals and
entities from participation in federal health care programs. Exclusion is
mandatory for those convicted of Medicarerelated crimes, patient abuse,
and certain health care fraud and controlled substance crimes. Exclusion
is permissive for other offenses, including professional health care
license revocation. See Pub. L. No. 105-33 S: 4331(c), 111 Stat. 251, 396;
42 U.S.C. S: 1320a-7.

the use of fraudulent degrees to obtain employment, VA requires that its
facilities compare the educational institutions listed by an applicant
against existing lists of "diploma mills" that sell fictitious college
degrees and other professional credentials.

    VA Policy Requires Background Investigations and Disclosures for Certain
    Employed Practitioners

VA's employed practitioners are required to undergo a background
investigation that verifies their personal histories.13 A background
investigation verifies, for instance, an individual's history of
employment, education, and residence. It also includes a fingerprint check
that searches for evidence of criminal activity by comparing fingerprints
against a database of criminal records. The Office of Personnel Management
(OPM) conducts the investigations for VA and reports its results back to
the facility that requested the investigation.

In conjunction with the background investigation, VA employed
practitioners are required to disclose information about their
professional and personal backgrounds by filling out the Declaration for
Federal Employment form-also known as form 306. Employed practitioners are
asked to disclose, among other things, information about criminal
convictions, employment terminations, military court-martials, and
delinquencies on federal loans. Failure to disclose information requested
on form 306 is grounds for dismissal. Facility officials compare the
information obtained from form 306 with the results obtained through the
background investigation to determine whether employed practitioners have
been forthcoming in their disclosures. If the background investigation
results include questionable issues, such as discrepancies in work or
criminal histories, the facility has 90 days to take action.

13Executive Order 10450, April 27, 1953, requires all persons employed by
federal departments and agencies to undergo a background investigation to
ensure that their employment is consistent with national security
interests. It is administered by the Office of Personnel Management (OPM),
which has issued implementing regulations in part 732 of Title 5 of the
Code of Federal Regulations. OPM may grant exemptions to the executive
order and, with regard to VA, background investigations are not required
for employees appointed for 6 months or less. Related regulations
regarding determinations of an individual's suitability for federal
employment, based on their character, conduct, knowledge, and ability, are
contained in part 732 of the Code of Federal Regulations.

  Gaps in Key VA Screening Requirements Create Vulnerabilities

Gaps in key VA screening requirements result in vulnerabilities when
screening certain health care practitioners. Although the screening
requirements for some occupations, such as physicians, are adequate
because they require verifying all licenses by contacting state licensing
boards, screening requirements for other occupations are less stringent.
These less stringent requirements do not require checking all licenses,
and they require physical inspection of one license only rather than
contacting the state licensing board. Similarly, VA does not require
contacting national certifying organizations to verify national
certificatesthe credentials held by health care practitioners,
such as respiratory therapists. Physical inspection of credentials alone
can be misleading; not all state licenses and national certificates
indicate whether they are restricted, and licenses and certificates can be
forged. While VA requires checking a national database for physicians and
dentists, it does not require that facility officials query a national
database that contains reports of disciplinary actions and criminal
convictions involving all licensed practitioners. In addition, VA does not
require that all practitioners undergo background investigations,
including fingerprinting, to check for criminal records. These gaps create
vulnerabilities because VA may remain unaware of health care practitioners
who could place patients at risk.

    VA Has Adequate Requirements for Verifying Professional Credentials of
    Certain Practitioners

VA's requirements for verifying the professional credentials of applicants
it intends to hire and employed practitioners in group A, such as
physicians and dentists, are complete and thorough. This is also the case
for applicants VA intends to hire in group B, such as nurses and
pharmacists. VA requires facility officials to verify all state licenses
by contacting the appropriate state licensing boards. To supplement these
requirements for physicians and dentists, VA officials also must query
FSMB and NPDB to identify reports of any disciplinary actions involving
these practitioners.

    Gaps Exist in VA's Requirements for Verifying Professional Credentials of
    Other Practitioners

In contrast to all practitioners in group A, the process for verification
of licenses for group B practitioners has gaps, as illustrated in figure
2. VA's verification process for group B practitioners that it intends to
hire is as stringent as the process used for group A practitioners.
However, the process used to verify licenses for continued employment of
group B practitioners is less stringent, because facility officials are
required to check only one state license, which is selected by the
practitioner. Furthermore, officials are not required to contact the state
licensing board directly, but instead may simply physically inspect the
one state license to check its status.

Figure 2: Gaps in Group B Employed Practitioners' Credentials Verification
with State Licensing Boards

Employed practitioners in group B with multiple state licenses select the
one state license under which they will continue to practice in VA. The
license selected does not have to be from the state where the VA facility
is located. VA officials check only that single license. As a result,
these employed practitioners could have a restricted license in one state,
or several restricted state licenses, but offer VA officials an
unrestricted license from another state for verification.

Moreover, the method required to periodically verify the status of
licenses for continued employment of practitioners in group B is not
thorough. VA facility officials are only required to physically inspect
the license- instead of contacting the state licensing board. VA facility
officials we interviewed were unaware of the inherent vulnerabilities in
relying on a physical inspection. According to licensing board officials,
one cannot determine with certainty that a license is valid and
unrestricted unless the state licensing board is contacted directly. These
officials explained that state licensing boards do not always exchange
information. Furthermore, physical inspection of licenses alone can be
misleading because not all state licensing boards mark a license to
indicate that it is restricted, and licenses can be forged, even though
licensing boards have taken steps to minimize this problem. Licensing
board officials also pointed out that many state boards do not charge a
fee to verify licenses.

Unlike the national database queries of FSMB for physicians and NPDB for
physicians and dentists, VA does not require facility officials to query
the Healthcare Integrity and Protection Data Bank (HIPDB), a national
database that contains information on disciplinary actions and criminal
convictions involving all licensed practitioners.14 All government
agencies, including state licensing boards, are required to report to
HIPDB. VA accesses HIPDB when it queries the NPDB for physicians and
dentists because the databases share information. However, VA does not
require its facilities to query HIPDB for all licensed practitioners even
though VA is authorized by statute to query this database at no charge.

VA's requirements for verifying the professional credentials of both
applicants and employed practitioners in group C also have gaps, as
illustrated in figure 3. For both applicants and employed practitioners in
group C, which include respiratory therapists and dietitians for example,
facility officials are only required to physically inspect the national
certificate to check its status. The physical inspection is required when
these practitioners apply for employment and periodically for continued
employment. Additionally, VA requires applicants in group C to disclose
all of the state licenses they have ever held, but does not require
facility officials to verify any of these state licenses.

14HIPDB was developed after the Health Insurance Portability and
Accountability Act of 1996 was enacted, which added new section 1128E to
the Social Security Act, requiring development of the database. See Pub.
L. No. 104-191, S: 221(a), 110 Stat. 1936, 2009 (codified at 42 U.S.C. S:
1320a-7e(2000)). The applicable regulations are contained in Part 61 of
Title 45 of the Code of Federal Regulations. HIPDB is maintained and
operated by the Health Resources and Services Administration in the
Department of Health and Human Services.

Figure 3: Gaps in Group C Applicants' and Employed Practitioners'
Credentials Verification with State Licensing Boards and National
Certifying Organizations

However, according to officials from national certifying organizations,
the authenticity and status of a national certificate can only be assured
by contacting the national certifying organizations directly. For example,
an official from the National Board for Respiratory Care told us that
practitioners that were certified prior to July 2002 are not required to
renew their certificates-they can voluntarily choose to recertify. Thus,
physical inspection of a certificate will not ensure that there has been
no disciplinary action taken by the board since the certificate was
issued.

    VA Has Not Implemented Consistent Background Screening Requirements

VA has not implemented consistent background screening requirements, which
include fingerprint checks, for all practitioners. Although VA requires
background investigations for newly hired employed practitioners, it does
not require background investigations for certain contract health care
practitioners, practitioners who work without compensation from VA,
medical consultants, and medical residents. VA, with prior approval from
OPM, has the authority to determine which positions in VA require a
background investigation. VA requested and received permission from OPM to
exempt certain categories of health care practitioners from background
investigations, based on VA's assessment

that these types of practitioners do not need a background investigation.
Table 1 lists the types of practitioners that VA exempts from background
investigations.

Table 1: Types of Practitioners VA Exempts from Background Investigations

Types of practitioners VA exempts Length of appointment

Contract health care  o  6 months or less in a single continuous
appointment

practitioners or practitioners or series of appointments
that work without direct
compensation from VA

Medical consultants  o  1 year or less and not reappointed

o  	1 year or more but less than 30 days in a calendar year and not
reappointed

Medical residents  o  1 year or less of continuous service at a VA
facility

Source: Department of Veterans Affairs, VA Manual MP-1, Part I, Chapter 5,
Change 1 (Washington, D.C.: 1979).

VA requested and received permission from OPM, in 2001 and 2003, to
perform fingerprint-only checks for contract health care practitioners,
who work in a facility for 6 months or less and are currently exempt from
background investigations, and for all volunteers who have access to
patients, patient information, or pharmaceuticals.15 OPM began to offer a
fingerprint-only checka new screening optionfor use by
federal agencies in 2001. Compared to background investigations, which
typically take several months to complete, fingerprint-only checks can be
obtained within 3 weeks or less and cost less than $25, about a quarter of
the cost of a background investigation.16 In commenting on a draft of this
report, VA said that it planned to implement fingerprint-only checks for
all contract health care practitioners, medical residents, medical
consultants, and practitioners that work without direct compensation from
VA, as well as certain volunteers. However, VA has not issued guidance to
its facilities instructing them to implement fingerprint-only checks on
all these practitioners. VA did issue guidance to its facilities to
implement fingerprint-only checks for volunteers who have access to
patients, patient information, or pharmaceuticals.

15VA's volunteer program is the largest in the federal government,
providing volunteers to assist veterans by augmenting staff in such
settings as hospitals and nursing homes.

16Departments and agencies may obtain fingerprints in two ways: either
using paper or using computerized technology, which became available in
1999. Computerized technology typically produces fingerprint match results
in 2 days.

  VA Facilities Did Not Comply with All of the Key VA Screening Requirements

Implementing fingerprint-only checks for practitioners who are currently
exempt from background investigations would detect practitioners with a
criminal history. According to the lead VA Office of Inspector General
investigator in the Dr. Swango case, if Dr. Swango had undergone a
fingerprint check at the VA facility where he trained, VA facility
officials would have identified his criminal history and could have taken
appropriate action. Additionally, one of the facilities we visited had
implemented fingerprint-only checks of medical residents training in the
facility and contract health care practitioners. An official at this
facility stated that at a minimum, fingerprint-only checks of medical
residents and contract practitioners were necessary to help ensure the
safety of veterans in the facility. FSMB in 1996 recommended that states
perform background investigations, including criminal history checks, on
medical residents in order to better protect patients because residents
have varying levels of unsupervised patient care. This recommendation, in
part, resulted from reports that over a 4-year period more than 500
residents had performance, behavioral, or criminal problems during their
training.

In the four facilities we visited, we found mixed compliance with the
existing key VA screening requirements which are intended to ensure that
applicants and employed practitioners at VA facilities have valid
professional credentials and personal backgrounds to deliver safe health
care to veterans. None of the four VA facilities complied with all of the
key requirements. Moreover, VA does not conduct oversight of its
facilities to determine if they comply with these key screening
requirements.

In order to show the variability in the level of compliance among the four
VA facilities we visited, we measured their performance against a
compliance rate of at least 90 percent for each of five of the six
screening requirements, even though VA allows no deviation from these
requirements. Table 2 summarizes the rate of compliance among the four VA
facilities we visited. For detailed information about our analysis and
each facility's compliance with a particular requirement, see appendixes I
and II. For the sixth requirementmatching the educational
institutions listed by a practitioner against lists of diploma
millswe asked facility officials if they did this check and then
asked them to produce the lists of diploma mills they use.

Table 2: Facilities' Rate of Compliance with Existing Key VA Screening
Requirements

                  Compliance with key screening requirementsa

Key screening requirements

Facility A Facility B Facility C Facility D

                  Credentials of applicants verified   A      W     A       A 
                             Credentials of employed                    
                              practitioners verified   W      W     W       W 
                    List of Excluded Individuals and                    
                     Entities queried for applicants   W      A     A       A 
                  Background investigation completed                    
                           or requested for employed                    
                                       practitioners   W      A     A       W 

Declaration for Federal Employment
form completed for employed
practitioners
(form 306) WWWW

Source: GAO analysis of VA facility files.

WIndicates a compliance rate of 90 percent or greater.

A Indicates a compliance rate of less than 90 percent.

Note: Some screening requirements do not require verifying all licenses a
practitioner might hold or verifying professional credentials by
contacting state licensing boards or national certifying organizations.

aTested for significance at the 95 percent confidence level.

All four facilities generally complied with VA's existing policies for
verifying the professional credentials of employed practitioners, either
by contacting the state licensing board for practitioners, such as
physicians, or physically inspecting the license or national certificate
for practitioners, such as nurses and respiratory therapists. They also
generally ensured that applicants VA intended to hire had completed the
Declaration for Federal Employment form, which requires the applicants to
disclose, among other things, information about criminal convictions,
employment terminations, and delinquencies on federal loans. However,
three of the four facilities did not follow VA's policies for verifying
all of the professional credentials of applicants and three facilities did
not compare applicants' names to LEIE prior to hiring them. Two of the
four facilities conducted background investigations on their employed
practitioners at least 90 percent of the time, but the other two
facilities did not.

We also asked officials whether their facilities checked the educational
institutions listed by an applicant against a list of diploma mills to
verify that the applicant's degree was not obtained from a fraudulent
institution.

An official at one of the four facilities told us his staff consistently
performed this check. Officials at the other three facilities stated they
did not perform the check because they did not have a list of diploma
mills.

In addition to assessing the rate of compliance with the key screening
requirements, we found that VA facilities varied in how quickly they took
action to deal with background investigations that returned questionable
results, such as discrepancies in work or criminal histories. OPM gives a
VA facility up to 90 days to take action after the facility receives
investigation results with questionable findings. We reviewed the
timeliness of actions taken by facility officials from August 1, 2002, to
August 23, 2003, at the four facilities we visited and six additional
facilities geographically spread across the VA health care system. We
found that officials at 5 of the 10 facilities took action within the
90-day time frame, with the number of days ranging on average from 13 to
68. Officials at 3 facilities exceeded the 90-day time frame on average by
36 to 290 days. One facility took action on its cases prior to OPM closing
the investigation, and another facility did not have the information
available to report. For additional information on the average number of
days it took each facility to report its actions, see appendix II.

One of the cases that exceeded the 90-day time frame involved a nursing
assistant who was hired to work in a VA nursing home in June 2002. In
August 2002, OPM sent the results of its background investigation to the
VA facility, reporting that the nursing assistant had been fired from a
non-VA nursing home for patient abuse. During our review, we found this
case among stacks of OPM results of background investigations that were
stored on a cart and in piles on the desk and on other work surfaces of a
clerk's office. After we brought this case to the attention of facility
officials in December 2003, they reviewed the report and then terminated
the employee for not disclosing this information on the Declaration for
Federal Employment form 306. The employee had worked at the VA facility
for more than 1 year.

Another case at the same facility that exceeded the 90-day time frame
involved an employee who had been convicted for possession of illegal
drugs prior to being hired by VA. He had been hired at the facility in
August 2002 and was to complete a background investigation form at that
time. In June 2003, almost 1 year after being hired, a facility official
realized the employee had not completed and returned this form and gave
the employee the form to complete. The employee returned the completed
form in the same month and it was sent to OPM, which returned the results
of its investigation to the facility in July 2003, before the

employee's probationary period of 1 year was completed. The OPM report
revealed numerous arrests for possession of illegal drugs. During our
December 2003 review and about 120 days after the investigation results
were returned from OPM, we found this report and brought it to the
attention of the facility director. Later, a facility official told us
that VA's regional counsel stated that since the employee's 1-year
probationary period had ended and the employee had disclosed this
information on the Declaration for Federal Employment form 306, the
facility could not take action to terminate the employee.

VA has not conducted oversight of its facilities' compliance with the key
screening requirements. Instead, VA has relied on OPM to do limited
reviews of whether facilities were meeting certain human resources
requirements, such as completion of background investigations. These
reviews did not include determining whether the facilities were verifying
professional credentials. Although VA established the Office of Human
Resources Oversight and Effectiveness in January 2003 to conduct such
oversight, the office has not conducted any facility compliance
evaluations. There is no VA policy outlining the human resources program
evaluations to be performed by this office, and the resources have not
been provided to support the functions of this office.

VA's screening requirements are intended to ensure the safety of veterans
by identifying applicants and employed practitioners with restricted or
fraudulent credentials, criminal backgrounds, or questionable work
histories. However, gaps in VA's existing screening requirements allow
some practitioners access to patients without a thorough screening of
their professional credentials and personal backgrounds. For example,
although the screening requirements for verifying professional credentials
for some occupations, such as physicians, are adequate, VA does not apply
the same screening requirements for all occupations with direct patient
care access. Specifically, VA does not require that all licenses be
verified, or that licenses and national certificates be verified by
contacting state licensing boards or national certifying organizations. VA
relies on two national databases to identify physicians and dentists who
have had disciplinary actions taken against them. In addition, VA accesses
a third national database, HIPDB, for physicians and dentists, because
HIPDB is linked to one of the two national databases VA currently
accesses. HIPDB is a national database that contains reports of
disciplinary actions and criminal convictions involving all licensed
practitioners, not just physicians and dentists. However VA does not
require facility officials to query HIPDB for all licensed practitioners.
As a result, practitioners such

  Conclusions

as nurses, pharmacists, and physical therapists do not have their state
licenses checked against a national database. In addition, VA does not
require all practitioners with direct patient care access, such as medical
residents, to have their fingerprints checked against a criminal history
database. These gaps create vulnerabilities that could allow incompetent
practitioners or practitioners with the intent to harm patients into VA's
health care system.

In addition to these gaps, compliance with the existing key screening
requirements was mixed at the four facilities we visited. None of the four
facilities complied with all of the key VA screening requirements.
However, all four facilities generally complied with VA's requirement to
periodically verify the credentials of practitioners for their continued
employment. Although VA created the Office of Human Resources Oversight
and Effectiveness in January 2003 expressly to provide oversight of VA's
human resources practices at its facilities, it has not provided resources
for this office to conduct oversight of VA facilities' compliance with
these requirements. Without such oversight, VA cannot provide reasonable
assurance that its facilities comply with requirements intended to ensure
the safety of veterans receiving health care in VA facilities. In light of
the gaps we found and mixed compliance with the key screening requirements
by VA facilities, we believe effective oversight could reduce the
potential risks to the safety of veterans receiving health care in VA
facilities.

Recommendations for To better ensure the safety of veterans receiving
health care at VA facilities, we recommend that the Secretary of Veterans
Affairs direct the Executive Action Under Secretary for Health to take the
following four actions:

o  	expand the verification requirement that facility officials contact
state licensing boards and national certifying organizations to include
all state licenses and national certificates held by applicants and
employed practitioners,

o  	expand the query of the Healthcare Integrity and Protection Data Bank
to include all licensed practitioners that VA intends to hire and
periodically query this database for continued employment,

o  	require fingerprint checks for all health care practitioners who were
previously exempted from background investigations and who have direct
patient care access, and

o  	conduct oversight to help ensure that facilities comply with all key
screening requirements for applicants and current employees.

  Agency Comments

In commenting on a draft of this report, VA generally agreed with our
findings and conclusions. VA acknowledged that we identified gaps in its
process for conducting background and credentialing checks and that we
provided what appeared to be reasonable recommendations to close those
gaps. VA stated that it would provide a detailed action plan to implement
our recommendations when the final report was issued.

VA said that our draft report inaccurately omitted VA's querying HIPDB for
practitioners who practice independently. We revised our report to clarify
that NPDB queries performed by VA automatically check HIPDB for these
practitioners because the databases are linked. However, VA does not
perform queries of HIPDB for the majority of its licensed practitioners,
which includes nurses, pharmacists, physical therapists, and dental
hygienists. VA also incorrectly stated that the draft report did not
include VA's requirement to query FSMB for physicians. In addition, VA
said that it planned to implement fingerprint-only checks for all contract
health care practitioners, medical residents, medical consultants, and
practitioners that work without direct compensation from VA, as well as
certain volunteers. However, VA has not issued guidance to its facilities
instructing them to implement fingerprint-only checks for all these
practitioners. Further, VA stated that the title of the report implied
that veterans are receiving inadequate care on a broad basis. We disagree.
The title reflects vulnerabilities created by the gaps in the screening of
practitioners that could place veterans at risk by allowing incompetent
practitioners or those with the intent to harm patients into VA's health
care system. VA provided technical comments which we incorporated, as
appropriate. VA's written comments are reprinted in appendix III.

As agreed with your office, unless you publicly announce its contents
earlier, we plan no further distribution of this report until 30 days
after its date. We will then send copies of this report to the Secretary
of Veterans Affairs and other interested parties. We also will make copies
available to others upon request. In addition, the report will be
available at no charge at the GAO Web site at http://www.gao.gov.

If you or your staff have any questions about this report, please call me
at (202) 512-7101. Another contact and key contributors are listed in
appendix IV.

Sincerely yours,

Cynthia A. Bascetta Director, Health Care-Veterans' Health and Benefits
Issues

                       Appendix I: Scope and Methodology

We examined VA's policies and practices that are intended to ensure that
health care practitioners at its facilities have appropriate credentials
and backgrounds to provide care to veterans. Specifically, we (1)
identified key VA screening requirements for its health care
practitioners, (2) determined the adequacy of these screening
requirements, and (3) assessed the extent to which selected VA facilities
complied with these screening requirements.

To identify key VA screening requirements for its health care
practitioners, we reviewed VA's policies and VA Handbook 5005, which
explains how to implement the screening policies. We limited our review to
43 occupations in VA that have direct patient care access or have an
impact on patient care. See table 3 for a list of the occupations included
in our review. To identify the 43 occupations, we consulted with VA human
resource officials. We interviewed human resource officials at VA
headquarters and at each facility we visited. We classified the
practitioners who are required to have professional credentialsa
state license or a national certificateinto three groups according
to VA's requirements for verifying these credentials. Groups A and B
represent practitioners who must be licensed to work in VA. However, the
requirements and process VA uses to verify professional credentials is
different for each of these groups. Group C represents practitioners who
must have a national certificate to work in VA and may also have a state
license. Practitioners not included in the three groups are not required
to have either a license or a national certificate to work in VA
facilities.

                       Appendix I: Scope and Methodology

Table 3: State Licensure and National Certification Requirements for the
43 VA Occupations

Occupations that do

Occupations that not require a state

Occupations that require a national license or a national Occupation
require a state license certificate to work in certificate to work in code
Occupation title to work in VA VA VA

Social Science X

Social Science Aid and Technician X

Psychology X

Psychology Aid and Technician X

Social Work X

Social Services Aid and Assistant X

Social Services X

Recreation Aid and Assistant X

Physiology X

General Health Science X

Medical Officer (Physician) X

Physician's Assistant X

Nurse Anesthetist X X

Registered Nursea X

Practical Nurse X

Nursing Assistant X

622 Medical Supply Aide/Technician X
630 Dietitian and Nutritionist X
631 Occupational Therapist X
633 Physical Therapist X
635 Corrective Therapist X
636 Rehabilitation Therapy Assistant X
638 Recreation/Creative Arts Therapist X
640 Health Aid and Technician X
644 Medical Technologist X
645 Medical Technician X
646 Pathology Technician X
647 Diagnostic Radiologic Technologist X
648 Therapeutic Radiologic Technologist X
649 Medical Instrument Technician X
651 Respiratory Therapistb X
660 Pharmacist X

                       Appendix I: Scope and Methodology

                                                                  Occupations 
                                                                      that do 
                                                 Occupations    not require a 
                                                     that               state 
                               Occupations that require a        license or a 
                                                national             national 
Occupation                   require a state certificate to certificate to 
                                        license work in               work in 
      code    Occupation          to work in VA       VA             VA       
                title                                          

Pharmacy Technician X

Optometrist X

Speech Pathology and Audiology X

Orthotist and Prosthetist X

Podiatrist X

Prosthetic Representative X

Dental Officer (Dentist) X

Dental Assistant X

Dental Hygiene X

1320 Chemistry X

1715 Vocational Rehabilitation X

Source: VA Handbook 5005, April 15, 2002.

aRegistered Nurse-includes nurse practitioners and clinical nurse
specialists.

To determine the adequacy of the key VA screening requirements, we
analyzed VA's policies and procedures to identify whether there were
inconsistencies in how the requirements were applied among various types
of practitioners. We interviewed VA headquarters and facility officials
and practitioners at the facilities we visited to determine how VA's
policies are implemented in facilities. In addition, we interviewed
representatives from 13 state licensing boards and the District of
Columbia Board of Nursing and 2 national certifying organizations to
determine if VA's requirements for verifying professional credentials are
adequate for identifying practitioners without valid and unrestricted
state licenses and national certificates.1

To assess the extent to which VA facilities we visited complied with the
key screening requirements, we chose a judgmental sample of four VA
facilities that varied in size, location, and medical school affiliations
to assess the extent to which these selected facilities complied with
these

1The licensing boards contacted were Alabama, Arkansas, California,
Delaware, District of Columbia, Florida, Indiana, Louisiana,
Massachusetts, New Jersey, New Mexico, Oregon, Texas, and Washington. The
national certifying organizations contacted were the National Board for
Respiratory Care and the National Board for Certification in Occupational
Therapy.

Appendix I: Scope and Methodology

requirements. The four facilities are located in Big Spring, Texas; New
Orleans, Louisiana; Seattle, Washington; and the District of Columbia. We
chose these facilities based on geographic variation, affiliations with
medical schools to train residents, and types of health care services
provided. Of the four facilities we visited, three are large facilities
located in major metropolitan areas and each are affiliated with at least
one medical school. The remaining facility is small, providing mainly
primary care and long-term care services to veterans and is located in a
rural area. For each facility, VA provided, from its automated pay system,
a list of current practitioners in the 43 occupations. As a result of
using VA's automated pay system, our sample does not include those
practitioners providing care through a contract or training agreement or
without direct compensation from VA. For each of the four facilities, we
selected a random sample of 100 practitioners either hired or assigned to
their current position no earlier than January 1, 1993. We chose to limit
our review to approximately the last 10 years because VA changed its
process for credentials verification in the early 1990s. For each of these
practitioners, we reviewed their personnel files to check that the
facility had complied with the following key VA screening requirements:

o  verify state licenses and national certificates for applicants;

o  verify state licenses and national certificates for employed
practitioners;

o  query the List of Excluded Individuals and Entities (LEIE) prior to
hire;

o  ensure completion of background investigations, including fingerprints;

o  	ensure completion of the Declaration for Federal Employment form, also
known as form 306; and

o  	verify that the educational institutions listed by a practitioner VA
intends to hire are checked against lists of diploma mills.

In order to show the variability in the level of compliance among the four
VA facilities we visited, we distinguished between facilities that had a
compliance rate of at least 90 percent for each of five of the six
screening requirements and those that did not. For each facility and key
screening requirement, we compared the percentage of personnel files found
in compliance to an acceptance level of 90 percent. In order to confirm
that a requirement had a compliance rate less than 90 percent, we
performed a one-sided significance test at the 95 percent confidence
level. See appendix II for detailed information on the four VA facilities'
compliance with each of the key VA screening requirements. Our results
from these four facilities cannot be generalized to other facilities. In
order to determine compliance with the key screening requirement to verify
that the educational institutions listed by a practitioner are not
fraudulent, we

Appendix I: Scope and Methodology

asked facility human resources staff if they performed this screening and
asked them to produce their lists of diploma mills.

Additionally, we reviewed VA facilities' response times to 214 background
investigation results returned from OPM with questionable issues, from
August 1, 2002, to August 23, 2003, at the four locations we visited and
six other VA facilities selected based on geographic location. The six
additional facilities were located in Boston, Massachusetts; East Orange,
New Jersey; Indianapolis, Indiana; Palo Alto, California; Portland,
Oregon; and San Diego, California. For these 10 facilities, we asked
officials to provide the date they took action on cases returned from OPM,
and from VA headquarters we obtained the dates when OPM returned the cases
to the facility. We determined the average number of days it took each
facility to take action after these cases were returned from OPM with
questionable issues. Our results cannot be generalized to other VA
facilities. See appendix II for detailed information on the results of our
analysis.

Appendix II: Results of Our Compliance Reviews at VA Facilities

Tables 4 and 5 show the sample counts used to measure compliance and the
results of our review for five of the requirements. Table 6 shows the
average number of days it took each facility to take action after cases
with questionable issues were returned from OPM.

Table 4: VA Facility Compliance with Key Screening
RequirementsProfessional Credentials Verification

Credentials of applicants verified

Credentials of employed practitioners verified

Number in sample

                                 Number where verification followed VA policy

Number where verification

Number in sample

                          Facility followed VA policy

                      Facility A       81             61                   74 
                      Facility B       77             71                   59 
                      Facility C       74             43                   67 
                      Facility D       62             47                   56 

Source: GAO analysis of facility files.

Note: The number of practitioners in the sample may be less than the
number of practitioner files reviewed at each facility because the
requirement may not apply to all VA applicants or employed practitioners.

  Table 5: Facility Compliance with Key Screening RequirementsPersonal
    Background Screening Declaration for Federal Employment form (form 306)
 completed for employed practitioners List of Excluded Individuals and Entities
                 (LEIE) queried for applicants prior to hiring

Background investigation completed or requested for employed practitioners

Number in sample

                Number with a completed or requested background investigation

Number with completed

Number in sample

Number queried prior to hire

Number in sampleFacility

                                    form 306

      Facility A        61        53        99a       93       94    
      Facility B        72        26        99b       27       93    
      Facility C        64         5        100       47       83    
      Facility D        66        39        100       98       92          86 

Source: GAO analysis of facility files.

Note: The number of practitioners in the sample may be less than the
number of practitioner files reviewed at each facility because the
requirement may not apply to all VA applicants or employed practitioners.

aOne personnel file was not available because the practitioner resigned
and the file was sent to storage.

bFacility B was unable to locate one personnel file; therefore, we sampled
99 files at that location.

Appendix II: Results of Our Compliance Reviews at VA Facilities

Table 6: Average Number of Days from Obtaining Background Investigation
Results to VA Facility Action (August 1, 2002, to August 23, 2003)

Average number of days for Number of background Facility facility action
investigation results reviewed

Facility A 13

Facility B 282

Facility C 21

Facility D -14a

Facility E 26

Facility F 34

Facility G 68

Facility H 126

Facility I 380

                 Facility J No data available No data available

Source: GAO analysis of facility data.

aA negative number of days indicates that the facility took action on its
cases before OPM returned the investigation results.

Appendix III: Comments from the Department of Veterans Affairs

Appendix III: Comments from the Department of Veterans Affairs

Appendix IV: GAO Contact and Staff Acknowledgments

GAO Contact Marcia A. Mann, (202) 512-9526

Acknowledgments 	In addition to the contact named above, Jacquelyn T.
Clinton, Jessica Cobert, Mary Ann Curran, Martha A. Fisher, Krister
Friday, Lesia Mandzia, and Marie Stetser made key contributions to this
report.

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To Report Fraud,	Contact: Web site: www.gao.gov/fraudnet/fraudnet.htm

  Waste, and Abuse in E-mail: [email protected]

Federal Programs Automated answering system: (800) 424-5454 or (202)
512-7470

Jeff Nelligan, Managing Director, [email protected] (202) 512-4800

Public Affairs 	U.S. General Accounting Office, 441 G Street NW, Room 7149
Washington, D.C. 20548
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